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BASIC PATIENT INFORMATION                                                                             

Patient name:  Surname _____________________  First name ______________________

Address: District ______________  Chiefdom____________   Town/village ____________

Sex:    Male     Female    

Estimated age:                      YEARS  MONTHS  (for children under 1 year)  

ADDITIONAL PATIENT INFORMATION                                                                             

 

Can patient eat:  Nothing      Liquid only     Semi-solid food       Solid food   

 

If Estimated Age is under 12 months (1 year) :  

       Gestation: Term-born ( 37wk GA)    Preterm (<37wk GA)      Unknown 

       Currently breastfed? YES  NO  Unknown   

 

Next of kin: Name ___________________________   Mobile # _____________________

Address:  District _____________________  Town/village _____________________

 

Any children (<18 years) at home without supervision?  YES   NO   UNKNOWN               

                  Number of children: [____]      List ages ______________________________               

Form completed by (write your name): _________________________________________

 

OBSERVATIONS

OBSERVATIONS

Current consciousness:  A      V      P    U          Confused/agitated:   YES     NO  

Temperature: [___][___] . [___] ° C   

Heart Rate: [___][___][___] beats /min         Respiratory Rate: [___][___] breaths /min         

Weight (kg) |___|___|.|___|                   

      If child under 5 years , Mid Upper Arm Circumference (cm):  |___|___|.|___| 

Systolic BP: [___][___][___] mmHg            Diastolic BP: [___][___][___] mmHg                                          

Capillary refill time (sec): [___] seconds   UNKNOWN     

O 2 saturation: [___][___][___] %     On: Room air   Supplemental Oxygen   Unknown

Clinically shocked? YES  NO  UNKNOWN    

 

SYMPTOMS (Ask open questions first then follow up with specific symptoms)

Number of days since earliest onset of symptoms: ____ days

Fever

Yes    No 

Chest pain

Yes    No 

Fatigue

Yes    No 

Sore throat

Yes    No 

Headache

Yes    No 

Decreased urine output

Yes    No 

Joint or muscle pain/aches

Yes    No 

Cough

Yes    No 

Loss of appetite

Yes    No 

Seizures

Yes    No 

Difficulty swallowing

Yes    No 

If BLEEDING , specify site:        

 

Nausea

Yes    No 

      Nose/mouth

Yes    No 

Vomiting

Yes    No 

Cough

Yes    No 

Diarrhoea

Yes    No 

Vomit

Yes    No 

Abdominal pain

Yes    No 

Urine

Yes    No 

Hiccups/hiccoughs

Yes    No 

Stool

Yes    No 

Breathing difficulty

Yes    No 

Vaginal (non-menstrual)

Yes    No 

Unable to eat

Yes    No 

 

 

Unable to drink

Yes    No 

Specify other symptoms:

 

Back pain

Yes    No 

 

OTHER MEDICAL HISTORY                             

Does the patient CURRENTLY have any known co-morbidities? tick all that apply  

      Tuberculosis   HIV      Heart disease    Diabetes  Asthma     

      Liver disease    Renal disease    Cancer   

           Other: ______________________________________________   

Does the patient have any known allergies?     YES  NO  UNKNOWN       

     If YES , List_____________________________________________

If patient is FEMALE:  

       Is the patient currently breastfeeding? YES  NO  UNKNOWN

        Is the patient: Pregnant  Postpartum (birth in last 6 weeks)   Neither  Unknown

                If PREGNANT:    Gestation age of fetus (nearest week):  [__][__] weeks   Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRE-EXISTING MEDICATIONS                             

  List all medications patient is taking/prescribed prior to admission (e.g. antibiotics, antivirals, antifungal, antimalarials, analgesic/antipyretics)

 

 

 

Name of medication (prefer generic name)

Dose and frequency

 

                                                        unknown

 

                                                        unknown

 

                                                        unknown

 

 

 

SIGNS

Bruising

  Yes    No 

Lower chest wall indrawing

Yes    No 

Pale/Anaemia

  Yes    No 

Abdominal tenderness

Yes    No 

Jaundice

  Yes    No 

Hepatomegaly

[_____] cm 

Rash

  Yes    No 

Splenomegaly

[_____] cm 

Conjunctival injection

  Yes    No 

Lymphadenopathy

Yes    No 

Elevated Jugular Venous Pressure (JVP)

  Yes    No 

 

 

CLINICAL IMPRESSION

Was the patient critically ill upon arrival?    YES  NO 

Did the patient display any of the following (check all that apply):

     Signs of shock   Unconsciousness   Severe dehydration    Convulsions  

     Anxiety/confusion 

What is your clinical diagnosis and differential? _________________________________

_________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL MANAGEMENT PLAN

Admit to:    WET ward     DRY ward

Frequency of nursing observations?    Every [___] hours

Target oral fluid intake?   [_____] ml per 24 hours       [____] ml per hour        

If on IV fluids , rate of infusion?     [_____] ml per 24 hours       [____] ml per hour        

 

***REMINDER: FILL THE PRESCRIPTION CHART

Have you filled the prescription chart?    YES  NO 

Other management?  _____________________________________________________

_______________________________________________________________________

 

Medications:  

Admissions pack                                            Cefixime                                                                          

Artemether-Lumefantrine (ACT)                Metronidazole                                                          

Artusunate                                                      Parecetamol

Quinine                                                            Tramadol                                                           

Ceftriaxone                                                     Morphine

Other medication?  Specify ____________________________________________________

___________________________________________________________________________